MINI REVIEW
published: 26 June 2015
Edited by:
Yuri Agrawal,
Johns Hopkins University, USA
Reviewed by:
Barry M. Seemungal,
Imperial College London, UK
Alejo Suarez,
British Hospital, Uruguay
*Correspondence:
Paul Hinckley Delano,
Physiology and Biophysics Program,
Otolaryngology Department, ICBM,
University of Chile, Independencia
1027, Santiago 8380453, Chile
pdelano@med.uchile.cl
Specialty section:
This article was submitted to
Neuro-otology, a section of the journal
Frontiers in Neurology
Received: 23 March 2015
Accepted: 12 June 2015
Published: 26 June 2015
Citation:
Fernández L, Breinbauer HA and
Delano PH (2015) Vertigo and
dizziness in the elderly.
Front. Neurol. 6:144.
doi: 10.3389/fneur.2015.00144
Frontiers in Neurology | www.frontiersin.org
doi: 10.3389/fneur.2015.00144
Vertigo and dizziness in the elderly
Lara Fernández 1 , Hayo A. Breinbauer 2,3 and Paul Hinckley Delano 1,4 *
1
Otolaryngology Department, Clinical Hospital of the University of Chile, Santiago, Chile, 2 Otolaryngology Department, San
Juan de Dios Hospital, University of Chile, Santiago, Chile, 3 Clínica Alemana de Santiago, Facultad de Medicina Clínica
Alemana, Universidad del Desarrollo, Santiago, Chile, 4 Physiology and Biophysics Program, Institute of Biomedical Sciences
(ICBM), Medicine Faculty, University of Chile, Santiago, Chile
The prevalence of vertigo and dizziness in people aged more than 60 years reaches
30%, and due to aging of world population, the number of patients is rapidly increasing.
The presence of dizziness in the elderly is a strong predictor of falls, which is the
leading cause of accidental death in people older than 65 years. Balance disorders in
the elderly constitute a major public health problem, and require an adequate diagnosis
and management by trained physicians. In the elderly, common causes of vertigo may
manifest differently, as patients tend to report less rotatory vertigo and more non-specific
dizziness and instability than younger patients, making diagnosis more complex. In this
mini review, age-related degenerative processes that affect balance are presented. Diag-
nostic and therapeutic approaches oriented to the specific impaired system, including
visual, proprioceptive, and vestibular pathways, are proposed. In addition, presbystasis –
the loss of vestibular and balance functions associated with aging – benign paroxysmal
positional vertigo, and stroke (in acute syndromes) should always be considered.
Keywords: dizziness, presbystasis, vertigo, falls, elderly, aging
Introduction
The terms dizziness and vertigo cover a variety of symptoms regarding disorders of spatial orienta-
tion and motion perception, such as the illusion of rotatory motion (classical rotatory vertigo) or the
feeling of unsteadiness, which can affect objectively the ability to achieve a stable gaze, posture, and
gait (1). Altogether they represent a common and serious issue in the elderly, where its prevalence
reaches 30% beyond 60 years of age (1, 2), while rising to 50% beyond 85 years (1).
The sole presence of dizziness in the elderly is a strong predictor of falls (3). Moreover, the presence
of abnormal balance tests increases the risk of hip and wrist fractures (4). Injuries related to falls
lead to mobility restriction and loss of independence, and increase the fear of falling, which also
predicts subsequent falls (2). In addition, falls are the leading cause of accidental death in persons
older than 65 years (5), while dizziness is one of the strongest contributors to the disability burden
after age 65 (6).
Although the majority of these patients present benign balance disorders, (7–9), in the elderly,
common causes of vertigo may manifest differently, with a more confusing constellation of symp-
toms, as patients tend to report less rotatory vertigo and more non-specific dizziness and instability
than younger patients presenting with the same condition (9). Underlying this phenomenon is the
progressive multimodal impairment of balance, including the loss of vestibular and proprioceptive
functions, and the impairment of central integration of these and other sensory inputs associated
with aging, which may also be called as presbystasis, presbyequilibrium, or multisensory dizziness
(4, 7, 10). In addition, the skeletal muscle strength and mass are reduced with aging, increasing the
risk of fall-related injuries in elderly patients (11).
1 June 2015 | Volume 6 | Article 144
Fernández et al.
On the other hand, a small number of patients harbor a seri-
ous and potentially life-threatening cause, mainly associated with
stroke, and this risk of more serious diagnoses increases with age
(12, 13). Altogether, vertigo, dizziness, and balance disorders in
the elderly constitute a major public health issue, which needs
adequate management by trained physicians. This mini review
presents recent advances in the diagnosis and management of
dizziness in elderly patients.
Pathophysiology of Balance in the Elderly
Age-related degeneration of different neural structures affects
balance, including the vestibular receptors, central vestibular neu-
rons, cerebellum, and visual and proprioceptive pathways. The
number of hair cells in the vestibular organs and the number of
fibers in the superior and inferior vestibular nerves decrease with
age (14–16). From a functional perspective, age-related deficits
appear to be larger on semicircular canals, followed by saccular
function, while the utriculus remains less affected (17–19). A
steady asymmetrical decrease in the ability of sensing angular
rotation with age has been reported, as assessed by video head
impulse testing (vHIT) of the vestibulo-ocular reflex (VOR) (4, 19,
20). This fact is associated with a loss of dynamic visual acuity due
to the inability to compensate fast head rotations with corrective
eye movements, thus assuring a steady image over the retina
(21). However, while on the acute phase of vestibular loss, this
may cause intense rotatory vertigo (due to a sudden vestibular
asymmetry), on elderly patients the slow onset of these chronic
impairments would not manifest with vertigo. Instead, they com-
plain about movement intolerance, instability, and insecure gait,
particularly when sudden turns are needed, as there is an inca-
pability of processing these movements properly. This may also
explain the observed lack of rotatory vertigo in elderly patients
with benign paroxysmal positional vertigo (BPPV) (8).
Nevertheless, while “active” vestibular symptoms may be
milder or shifted toward instability, functional balance perfor-
mance and disequilibrium phenomena are actually more severe.
The sole presence of VOR asymmetry (which may present in
elderly patients without history of an acute vestibular syndrome,
and rarely in the form of bilateral vestibulopathy) is a significant
predictor of falling (4, 22). In addition, compensation phenomena
after vestibular loss are weakened in elderly patients, for example,
impairment after vestibular neuritis is harsher on the elderly (23).
Behind this lies degeneration of multiple non-vestibular subsys-
tems. For instance, the medial vestibular nucleus, important in
vestibular compensation due to its commissural fibers, shows
lower neuron density in healthy older adults (24). There is also
a mean loss of cerebellum Purkinje cells of about 2.5% per decade
(25). Vibration and touch thresholds, the ability to detect position
and direction of joint movements, and muscle strength also deteri-
orate with age (2). Visual accommodation, depth perception, and
the ability to suppress nystagmus by visual fixation is diminished
due to aging of the oculomotor system with increased saccade
latency, and reduced eye tracking velocity (2).
Similarly, elderly patients with chronic pathological asymmet-
ric vestibular evoked myogenic potentials (VEMPs) or deviated
subjective visual vertical (SVV) tests, do not report dizziness
Frontiers in Neurology | www.frontiersin.org
Vertigo and dizziness in the elderly
or vertigo as significant symptoms, which may relate to central
compensation occurring from the beginning of this slow onset
of vestibular function (18, 19, 26, 27). This scenario leads to
no pathological symptoms at all. Therefore, it is still controver-
sial whether presbystasis by itself should be always considered
pathological or not.
In summary, in order to maintain balance, the brain uses all
available sensorial cues from vestibular, visual, and propriocep-
tive inputs, which in turn are integrated by the central nervous
system to execute adequate motor responses. In this manner,
age-related balance deterioration does not appear to behave as a
unique standardized phenomenon, but the opposite, it seems to be
extremely variable from patient to patient (17, 18, 20, 27). More-
over, minor new or acute impairments can affect disproportion-
ately their capacity to cope difficult equilibrium scenarios, as every
sensory modality may already be partially deteriorated. Current
knowledge is moving toward determining which abnormalities
in balance testing relate to higher risk of falling, and toward a
balance disorder “profile” of selective impairments, which, as we
propose, may guide a target-specific treatment (28–30). While
asymmetric, severe, and multimodal balance impairments due to
aging are likely to cause symptomatology per se, the magnification
and distortion of the symptom spectrum of specific pathologies by
presbystasis is perhaps more common. All these factors should be
taken into account in the diagnosis and management of elderly
patients.
Diagnosis of Dizziness in the Elderly
Reaching a complete, meaningful, and treatment-oriented diag-
nosis in elderly dizzy patients remains an important challenge for
even the most experienced clinician. Obtaining a good clinical
history can be a tough task. It has been reported that more than
half of elderly patients with balance disorders are vague, inconsis-
tent, or contradictory in describing their symptoms (31). Besides,
there is not a single symptom that can predict with specificity
the underlying causes of dizziness, and most of the times, elderly
patients have more than one cause of dizziness (32, 33). Moreover,
caloric test responses depend on several factors that could be
affected by age, such as ear canal volume, temporal bone thick-
ness, and blood supply to the temporal bone (34). Several studies
have found that caloric responses tend to increase in middle age
with a peak between 50 and 70 years, and then decline modestly
thereafter (35, 36).
A systematic assessment of balance should be achieved in this
type of patient, for which recent technological developments are of
great assistance. The impairment of each of the three semicircular
canals can be examined by means of vHIT (37) procuring a
reliable, objective, and quantitative value for VOR. Ocular and
cervical VEMPs give equally reliable information over utricular
and saccular function independently (38). The non-vestibular
proprioceptive and visual sensory components of balance and
their central integration in overall equilibrium performance can
be thoroughly assessed by dynamic computed posturography (39).
Altogether these tests provide an objective assessment of every
component and subsystem of balance, allowing specific profiling
of patients (40, 41).
2 June 2015 | Volume 6 | Article 144
Fernández et al. Vertigo and dizziness in the elderly

Besides HIT, the SVV bucket test and modified Romberg and TABLE 1 | Etiology of dizziness and vertigo in the elderly.
Fukuda tests represent low complexity alternatives for the same
Peripheral vestibular Benign paroxysmal positional vertigo
assessment, and may be used to develop simple, low cost, and
Vestibular neuritis
quick screening procedures (20, 42). SVV by means of bucket test
Bilateral vestibular loss
may even provide sensible assessment of utricular components
beyond VEMP contributions (27). Head-shaking nystagmus and Late-onset Meniere’s disease or
decompensation (2)
dynamic visual acuity testing among others constitute bedside,
Labyrinthitis
fast, inexpensive, and easy to interpret vestibular tests for VOR (4,
7, 18). Testing for postural hypotension, joint position sense, and Occlusion of the anterior vestibular artery (48)

gait disorders can also contribute to assess non-vestibular compo- Central nervous system Vestibular migraine (49)
nents in a bedside low-cost manner, contributing to designing an
Transient ischemic attack of vertebrobasilar
integral but component-specific treatment. artery (50)
A particular scenario exists in acute onset of severe dizziness Stroke
or vertigo; an acute vestibular syndrome, where ruling out stroke
Neurodegenerative disorders (51)
is critical, particularly in the elderly. The HINTS assessment
Downbeat and upbeat nystagmus syndromes (51)
protocol (head impulse test, nystagmus directionality, and test
of skew) can be performed at the bedside, with high sensitivity Cardiovascular (2) Arrhythmia
and specificity to diagnose stroke in an acute vestibular syndrome Postural hypotension
(43). This three-step bedside oculomotor examination has shown Congestive heart failure
better sensitivity than early magnetic resonance imaging (MRI). Heart valve failure
MRI can give a false negative result in vertebrobasilar stroke
(44), and is not always readily available (45). A full description Medications (52) Antihypertensive
of the management of acute vertigo in the elderly is beyond Benzodiazepines
the scope of this mini review, further readings can be obtained Hypnotics
elsewhere (13, 46). Anxiolytics
Also, of note is positional testing for BPPV. This clinical entity Antiepileptic
accounts for one in every three causes of dizziness in the elderly.
With a simple diagnosis–treatment scheme (even in the absence Multimodal balance disorder Presbystasis (10)
of rotatory symptoms), testing should be performed routinely
Others Primary and secondary neoplasia (breast and
(8). Consequently, to seek a precise diagnosis, it seems to be
prostate) (53, 54)
mandatory to obtain a good clinical history and perform thorough
Somatoform vertigo and psychiatric dizziness (55)
neuro-otologic bedside examination, including postural testing,
Musculoskeletal system disorders
while the majority of patients may benefit from vestibular tests,
and stroke assessment protocols for an acute balance disorder. Proprioception and somatosensory loss

Etiology
The majority of diseases that cause dizziness in any age group
become more prevalent in older individuals. This can be explained
by the cumulative probability of exposure or by age-related
changes that make the elderly more susceptible to these patholo-
gies (47). A summary of the main causes of dizziness in the elderly
is shown in Table 1.
Management of Elderly Patients with
Dizziness
As with younger patients, disease-specific therapies should be
provided, such as repositioning maneuvers for BPPV and reha-
bilitation exercises for vestibular hypofunction. Nevertheless, spe-
cial consideration is needed for elderly. A flowchart for the
management of these patients is proposed in Figure 1. A high
level of suspicion for BPPV should be maintained. In dubi-
ous cases, treatment attempts should be preferred, given dimin-
ished symptomatology and the safety and simplicity of reposition
maneuvers (56).
In acute syndromes, stroke should always be ruled out by
HINTS. Vestibular suppressants should be tapered quickly due
to their inhibitory effect on central compensation (57). Although
steroids have been proven to diminish functional loss over time,
they may not contribute to acute symptomatic relief (58). Steroids
side effects should be carefully considered before administration,
particularly on this age group.
Current knowledge advises the initiation of vestibular rehabili-
tation (VR) as soon as possible after an acute vestibular syndrome
(29, 30). VR works as a catalyzer and enhancer of central com-
pensation on the basis of three principles: adaptation (rearrange-
ment of VOR networking), substitution (strengthening of non-
vestibular components of balance), and habituation (increase of
sensory thresholds).
Chronic dizziness derived from previously acquired vestibular
loss (vestibular neuritis, bilateral vestibulopathy among others)
has good results with VR, particularly in terms of independence
and quality of life, although it may need longer and more inten-
sive therapy (28, 59). Moreover, VR is indicated in presbystasis,
whereas the objective is to reduce symptoms or decrease the
risk of falling (29, 30, 60). In addition, if there are deficits in
lower extremity muscle strength, specific therapies directed to
locomotor dysfunctions should be indicated (61). Proper balance

Frontiers in Neurology | www.frontiersin.org 3 June 2015 | Volume 6 | Article 144

Fernández et al.
FIGURE 1 | Proposed flowchart for the management of dizziness in
elderly patients. An accurate anamnesis and physical examination will
determine further vestibular, neurological, or cardiovascular tests. Patients with
chronic vertigo should be evaluated with Dix–Hallpike maneuvers. After that,
characterizations may help in designing more specific and effi-
cient interventions. For instance, a patient lacking postural sta-
bility will require postural- and gait-focused therapy. Care should
be taken in focusing therapy on ongoing symptoms rather than
solely on testing abnormalities, as certain patients could require
other treatments prior to benefit from VR, such as in the case of
vestibular migraine, or visually induced dizziness, among others.
Importantly, spontaneous compensation strategies differ
among patients (half of the population tend to rely on visual cues,
while the other half rely on postural information), supporting the
need for customized rehabilitation programs (30). Computerized
dynamic posturography seems to allow such characterization,
while being a reliable objective measurement of the “amount” of
unbalance and risk of falling, and monitoring progress (30).
Initiatives using Internet resources and mobile devices to sup-
port adherence and the realization of rehabilitation exercises at
home have been developed (60, 62). Other balance-improving
treatments being currently explored include biofeedback devices
worn all day, which give tactile or acoustic cues when the center of
gravity is being lost, allowing the patient to react accordingly (63).
In severe cases of bilateral VOR loss and inadequate compensation
strategies, the role of vestibular implants (devices similar in their
concept to cochlear implants) is beginning to be explored, and
interventions have already been made in the first patients with
satisfying functional outcomes (64).
Conclusion
Dizziness in the elderly remains a difficult subject, given the
underlying factor of vestibular impairment due to aging in the
Frontiers in Neurology | www.frontiersin.org
Vertigo and dizziness in the elderly
and depending on the available resources, office or laboratory tests help to
estimate the risk of falling and define the balance profile to guide the
management of these patients. On the other hand, every acute patient should
be evaluated with the HINTS protocol.
form of presbystasis. The diagnostic and therapeutic approach
must be multi-systemic and oriented to the visual, proprioceptive,
and vestibular systems. BPPV and stroke (particularly in acute
syndromes) should always be considered, given the frequency of
the first and the severity of the latter.
Current vestibular testing allows a complete characterization
of balance function and its deficits, and is becoming useful as a
guide to planning treatment, where a cause-specific pathology is
present, or presbystasis is the sole issue. Under this last condition,
VR should be considered in the elderly where no other plausible
balance disorder is suspected, in order to treat a probably symp-
tomatic presbystasis. Here, resolution of symptomatology would
confirm the assumed working hypothesis of presbystasis, while
lack of progress would lead to further exploration of less common
causes.
Future challenges on the subject include the further determi-
nation of vestibular impairment profiles and their specific VR
alternatives, in order to achieve the shortest and most efficient
therapy possible. However, research should also focus on pre-
ventive efforts to avoid falls. The threshold between what may
be considered non-significant vestibular abnormalities and those
correlating with a higher risk of falling should be better explored.
This will inevitably lead to the establishment of a reasonable
battery of (hopefully, bedside, low-cost, easy to interpret) exam-
inations designed to rule out unacceptable risk for falling, in the
fashion of the HINTS protocol for stroke.
Acknowledgments
Dr. PHD is funded by Fundación Guillermo Pulema.
4 June 2015 | Volume 6 | Article 144
Fernández et al.
References
1. Jonsson R, Sixt E, Landahl S, Rosenhall U. Prevalence of dizziness and vertigo
in an urban elderly population. J Vestib Res (2004) 14:47–52.
2. Barin K, Dodson EE. Dizziness in the elderly. Otolaryngol Clin North Am (2011)
44:437–54. doi:10.1016/j.otc.2011.01.013
3. Agrawal Y, Carey JP, Della Santina CC, Schubert MC, Minor LB. Disorders of
balance and vestibular function in US adults: data from the national health and
nutrition examination survey, 2001-2004. Arch Intern Med (2009) 169:938–44.
doi:10.1001/archinternmed.2009.66
4. Ekvall Hansson E, Magnusson M. Vestibular asymmetry predicts falls among
elderly patients with multi-sensory dizziness. BMC Geriatr (2013) 13:77. doi:10.
1186/1471-2318-13-77
5. Kannus P, Parkkari J, Koskinen S, Niemi S, Palvanen M, Jarvinen M, et al.
Fall-induced injuries and deaths among older adults. JAMA (1999) 281:1895–9.
doi:10.1001/jama.281.20.1895
6. Mueller M, Strobl R, Jahn K, Linkohr B, Peters A, Grill E. Burden of disability
attributable to vertigo and dizziness in the aged: results from the KORA-Age
study. Eur J Public Health (2014) 24:802–7. doi:10.1093/eurpub/ckt171
7. Tuunainen E, Jantti P, Poe D, Rasku J, Toppila E, Pyykko I. Characterization of
presbyequilibrium among institutionalized elderly persons. Auris Nasus Larynx
(2012) 39:577–82. doi:10.1016/j.anl.2011.12.004
8. Batuecas-Caletrio A, Trinidad-Ruiz G, Zschaeck C, Del Pozo De Dios JC, De
Toro Gil L, Martin-Sanchez V, et al. Benign paroxysmal positional vertigo in
the elderly. Gerontology (2013) 59:408–12. doi:10.1159/000351204
9. Piker EG, Jacobson GP. Self-report symptoms differ between younger and
older dizzy patients. Otol Neurotol (2014) 35:873–9. doi:10.1097/MAO.000000
0000000391
10. Tuunainen E, Poe D, Jantti P, Varpa K, Rasku J, Toppila E, et al. Presbyequilib-
rium in the oldest old, a combination of vestibular, oculomotor and postural
deficits. Aging Clin Exp Res (2011) 23:364–71. doi:10.3275/7623
11. Woo N, Kim SH. Sarcopenia influences fall-related injuries in community-
dwelling older adults. Geriatr Nurs (2014) 35:279–82. doi:10.1016/j.gerinurse.
2014.03.001
12. Dagan E, Wolf M, Migirov LM. Why do geriatric patients attend otolaryngology
emergency rooms? Isr Med Assoc J (2012) 14:633–6.
13. Saber Tehrani AS, Kattah JC, Mantokoudis G, Pula JH, Nair D, Blitz A,
et al. Small strokes causing severe vertigo: frequency of false-negative MRIs
and nonlacunar mechanisms. Neurology (2014) 83:169–73. doi:10.1212/wnl.
0000000000000573
14. Johnsson LG. Degenerative changes and anomalies of the vestibular sys-
tem in man. Laryngoscope (1971) 81:1682–94. doi:10.1288/00005537-197110
000-00016
15. Richter E. Quantitative study of human Scarpa’s ganglion and vestibu-
lar sensory epithelia. Acta Otolaryngol (1980) 90:199–208. doi:10.3109/
00016488009131716
16. Merchant SN, Velazquez-Villasenor L, Tsuji K, Glynn RJ, Wall C III, Rauch SD.
Temporal bone studies of the human peripheral vestibular system. Normative
vestibular hair cell data. Ann Otol Rhinol Laryngol Suppl (2000) 181:3–13.
17. Agrawal Y, Ward BK, Minor LB. Vestibular dysfunction: prevalence, impact
and need for targeted treatment. J Vestib Res (2013) 23:113–7. doi:10.3233/
ves-130498
18. Davalos-Bichara M, Agrawal Y. Normative results of healthy older adults on
standard clinical vestibular test. Otol Neurotol (2014) 35:297–300. doi:10.1097/
MAO.0b013e3182a09ca8
19. Li C, Layman AJ, Geary R, Anson E, Carey JP, Ferrucci L, et al. Epidemiology
of vestibulo-ocular reflex function: data from the Baltimore longitudinal
study of aging. Otol Neurotol (2015) 36:267–72. doi:10.1097/MAO.
0000000000000610
20. Agrawal Y, Davalos-Bichara M, Zuniga MG, Carey JP. Head impulse test
abnormalities and influence on gait speed and falls in older individuals. Otol
Neurotol (2013) 34:1729–35. doi:10.1097/MAO.0b013e318295313c
21. Ishigaki H, Miyao M. Implications for dynamic visual acuity with changes in
aged and sex. Percept Mot Skills (1994) 78:363–9. doi:10.2466/pms.1994.78.2.
363
22. Tuunainen E, Rasku J, Jantti P, Pyykko I. Risk factors of falls in community
dwelling active elderly. Auris Nasus Larynx (2014) 41:10–6. doi:10.1016/j.anl.
2013.05.002
Frontiers in Neurology | www.frontiersin.org
Vertigo and dizziness in the elderly
23. Fujimoto C, Egami N, Kinoshita M, Sugasawa K, Yamasoba T, Iwasaki S.
Involvement of vestibular organs in idiopathic sudden hearing loss with ver-
tigo: an analysis using oVEMP and cVEMP testing. Clin Neurophysiol (2015)
126:1033–8. doi:10.1016/j.clinph.2014.07.028
24. Alvarez JC, Díaz C, Suárez C, Fernández JA, González del Rey C, Navarro
A, et al. Neuronal loss in human medial vestibular nucleus. Anat Rec (1998)
251:431–8. doi:10.1002/(SICI)1097-0185(199808)251:4<431::AID-AR2>3.3.
CO;2-D
25. Yesmin T, Ara S, Umar BU, Rahman M, Afroz H, Sultana K, et al. Numbers
of Purkinje cell with increasing age-a post mortem study. Faridpur Med Coll J
(2011) 6:92–4. doi:10.3329/fmcj.v6i2.9209
26. Tourtillott BM, Ferraro JA, Bani-Ahmed A, Almquist E, Deshpande N. Age-
related changes in vestibular evoked myogenic potentials using a modified
blood pressure manometer feedback method. Am J Audiol (2010) 19:100–8.
doi:10.1044/1059-0889(2010/10-0021)
27. Sun DQ, Zuniga MG, Davalos-Bichara M, Carey JP, Agrawal Y. Evaluation of
a bedside test of utricular function – the bucket test – in older individuals. Acta
Otolaryngol (2014) 134:382–9. doi:10.3109/00016489.2013.867456
28. Alrwaily M, Whitney SL. Vestibular rehabilitation of older adults with dizziness.
Otolaryngol Clin North Am (2011) 44:473–96. doi:10.1016/j.otc.2011.01.015
29. Cabrera-Kang C, Tusa R. Vestibular rehabilitation: rationale and indications.
Semin Neurol (2013) 33:276–85. doi:10.1055/s-0033-1354593
30. Deveze A, Bernard-Demanze L, Xavier F, Lavieille JP, Elziere M. Vestibular
compensation and vestibular rehabilitation. Current concepts and new trends.
Neurophysiol Clin (2014) 44:49–57. doi:10.1016/j.neucli.2013.10.138
31. Newman-Toker DE, Cannon LM, Stofferahn ME, Rothman RE, Hsieh YH,
Zee DS. Imprecision in patient reports of dizziness symptom quality: a cross-
sectional study conducted in an acute care setting. Mayo Clin Proc (2007)
82:1329–40. doi:10.4065/82.11.1329
32. Lawson J, Fitzgerald J, Birchall J, Aldren CP, Kenny RA. Diagnosis of geriatric
patients with severe dizziness. J Am Geriatr Soc (1999) 47:12–7. doi:10.1111/j.
1532-5415.1999.tb01895.x
33. Kerber KA, Brown DL, Lisabeth LD, Smith MA, Morgenstern LB. Stroke
among patients with dizziness, vertigo, and imbalance in the emergency depart-
ment: a population-based study. Stroke (2006) 37:2484–7. doi:10.1161/01.STR.
0000240329.48263.0d
34. Enrietto JA, Jacobson KM, Baloh RW. Aging effects on auditory and vestibular
responses: a longitudinal study. Am J Otolaryngol (1999) 20:371–8. doi:10.1016/
S0196-0709(99)90076-5
35. Bruner A, Norris TW. Age-related changes in caloric nystagmus. Acta Otolaryn-
gol Suppl (1971) 282:1–24.
36. Mulch G, Petermann W. Influence of age on results of vestibular function tests.
Review of literature and presentation of caloric test results. Ann Otol Rhinol
Laryngol Suppl (1979) 88:1–17.
37. MacDougall H, Weber K, McGarvie LA, Halmagyi GM, Curthoys IS. The video
head impulse test: diagnostic accuracy in peripheral vestibulopathy. Neurology
(2009) 73:1134–41. doi:10.1212/WNL.0b013e3181bacf85
38. Brantberg K. Vestibular evoked myogenic potentials (VEMPs): useful-
ness in clinical neurotology. Semin Neurol (2009) 29:541–7. doi:10.1055/
s-0029-1241042
39. Soto-Varela A, Faraldo-Garcia A, Rossi-Izquierdo M, Lirola-Delgado A,
Vaamonde-Sanchez-Andrade I, Del-Rio-Valeiras M, et al. Can we predict the
risk of falls in elderly patients with instability? Auris Nasus Larynx (2015)
42(1):8–14. doi:10.1016/j.anl.2014.06.005
40. Curthoys I, Topple A, Halmagyi G. Unilateral vestibular deafferentation (UVD)
causes permanent asymmetry in the gain of the yaw VOR to high acceleration
head impulses in guinea pigs. Acta Otolaryngol Suppl (1995) 520:59–61. doi:10.
3109/00016489509125190
41. Curthoys I. The interpretation of clinical tests of peripheral vestibular function.
Laryngoscope (2012) 122:1342–52. doi:10.1002/lary.23258
42. Cohen HS, Mulavara AP, Peters BT, Sangi-Haghpeykar H, Bloomberg JJ. Stand-
ing balance tests for screening people with vestibular impairments. Laryngo-
scope (2014) 124:545–50. doi:10.1002/lary.24314
43. Kattah JC, Talkad AV, Wang DZ, Hsieh YH, Newman-Toker DE.
HINTS to diagnose stroke in the acute vestibular syndrome: three-step
bedside oculomotor examination more sensitive than early MRI diffusion-
weighted imaging. Stroke (2009) 40:3504–10. doi:10.1161/STROKEAHA.109.
551234
5 June 2015 | Volume 6 | Article 144
Fernández et al.
44. Oppenheim C, Stanescu R, Dormont D, Crozier S, Marro B, Samson Y, et al.
False-negative diffusion-weighted MR findings in acute ischemic stroke. AJNR
Am J Neuroradiol (2000) 21:1434–40.
45. Edlow JA, Newman-Toker DE, Savitz SI. Diagnosis and initial manage-
ment of cerebellar infarction. Lancet Neurol (2008) 7:951–64. doi:10.1016/
S1474-4422(08)70216-3
46. Newman-Toker D, Saber A, Mantokoudis G, Pula JH, Guede CI, Kerber KA,
et al. Quantitative video-oculography to help diagnose stroke in acute vertigo
and dizziness – toward an ECG for the eyes. Stroke (2013) 44:1158–61. doi:10.
1161/STROKEAHA.111.000033
47. Lo AX, Harada CN. Geriatric dizziness: evolving diagnostic and therapeutic
approaches for the emergency department. Clin Geriatr Med (2013) 29:181–204.
doi:10.1016/j.cger.2012.10.004
48. Pardal Refoyo JL, Perez Plasencia D, Beltran Mateos LD. [Ischemia of the ante-
rior vestibular artery (Lindsay-Hemenway syndrome). Review and comments].
Acta Otorrinolaringol Esp (1998) 49:599–602.
49. Furman JM, Balaban CD. Vestibular migraine. Ann N Y Acad Sci (2015)
1343:90–6. doi:10.1111/nyas.12645
50. Paul NLM, Simoni M, Rothwell PM. Transient isolated brainstem symptoms
preceding posterior circulation stroke: a population-based study. Lancet Neurol
(2013) 12:65–71. doi:10.1016/s1474-4422(12)70299-5
51. Strupp M, Kremmyda O, Adamczyk C, Bottcher N, Muth C, Yip CW,
et al. Central ocular motor disorders, including gaze palsy and
nystagmus. J Neurol (2014) 261(Suppl 2):S542–58. doi:10.1007/
s00415-014-7385-9
52. Shoair OA, Nyandege AN, Slattum PW. Medication-related dizziness in the
older adult. Otolaryngol Clin North Am (2011) 44:455–71. doi:10.1016/j.otc.
2011.01.014
53. Gloria-Cruz TI, Schachern PA, Paparella MM, Adams GL, Fulton SE. Metas-
tases to temporal bones from primary nonsystemic malignant neoplasms.
Arch Otolaryngol Head Neck Surg (2000) 126:209–14. doi:10.1001/archotol.126.
2.209
54. Alvo A, Miranda G, Delano PH. Imaging case of the month: metastatic prostate
adenocarcinoma presenting as hearing loss and disequilibrium. Otol Neurotol
(2012) 33:e79–80. doi:10.1097/MAO.0b013e3182713c4a
55. Staab JP. Chronic dizziness: the interface between psychiatry and neuro-
otology. Curr Opin Neurol (2006) 19:41–8. doi:10.1097/01.wco.0000198102.
95294.1f
Frontiers in Neurology | www.frontiersin.org
Vertigo and dizziness in the elderly
56. Bhattacharyya N, Baugh RF, Orvidas L, Barrs D, Bronston LJ, Cass S, et al.
Clinical practice guideline: benign paroxysmal positional vertigo. Otolaryngol
Head Neck Surg (2008) 139:S47–81. doi:10.1016/j.otohns.2008.08.022
57. Strupp M, Brandt T. Vestibular neuritis. Semin Neurol (2009) 29:509–19. doi:10.
1055/s-0029-1241040
58. Strupp M, Zingler V, Arbusow V, Nicklas D, Maag K, Dieterich M, et al.
Methylprednisolone, valacyclovir or the combination for vestibular neuritis. N
Engl J Med (2004) 351:354–9. doi:10.1056/NEJMoa033280
59. Jung JY, Kim JS, Chung PS, Woo SH, Rhee CK. Effect of vestibular rehabilitation
on dizziness in the elderly. Am J Otolaryngol (2009) 30:295–9. doi:10.1016/j.
amjoto.2008.06.013
60. Huang K, Sparto PJ, Kiesler S, Siewiorek DP, Smailagic A. iPod-based in-home
system for monitoring gaze-stabilization exercise compliance of individuals
with vestibular hypofunction. J Neuroeng Rehabil (2014) 11:69. doi:10.1186/
1743-0003-11-69
61. Howe TE, Rochester L, Neil F, Skelton DA, Ballinger C. Exercise for improving
balance in older people. Cochrane Database Syst Rev (2011) 11:CD004963.
doi:10.1002/14651858.CD004963.pub3
62. Geraghty AW, Kirby S, Essery R, Little P, Bronstein A, Turner D, et al. Internet-
based vestibular rehabilitation for adults aged 50 years and over: a protocol
for a randomised controlled trial. BMJ Open (2014) 4:e005871. doi:10.1136/
bmjopen-2014-005871
63. Horak F, King L, Mancini M. Role of body-worn movement monitor technology
for balance and gait rehabilitation. Phys Ther (2015) 95:461–70. doi:10.2522/ptj.
20140253
64. Pelizzone M, Fornos AP, Guinand N, Van De Berg R, Kos I, Stokroos R, et al.
First functional rehabilitation via vestibular implants. Cochlear Implants Int
(2014) 15(Suppl 1):S62–4. doi:10.1179/1467010014z.000000000165
Conflict of Interest Statement: The authors declare that the research was con-
ducted in the absence of any commercial or financial relationships that could be
construed as a potential conflict of interest.
Copyright © 2015 Fernández, Breinbauer and Delano. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (CC BY).
The use, distribution or reproduction in other forums is permitted, provided the
original author(s) or licensor are credited and that the original publication in this
journal is cited, in accordance with accepted academic practice. No use, distribution
or reproduction is permitted which does not comply with these terms.
6 June 2015 | Volume 6 | Article 144